Download Ebola Virus Disease in West Africa — Clinical Manifestations and

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Access to Data from Industry-Sponsored Clinical Trials
duct a scientific review of each
proposal before passing it along
to the committee — we declined,
believing that such an approach
would compromise our independence.
The system described here
will undoubtedly evolve considerably over time. Management of the
proposals is likely to be turned
over to an independent organization, a development that should
make it more appealing for other
manufacturers to join and should
enhance public confidence in the
process. We hope that academic
researchers will be adding their
data to such systems in the future.
Some of us believe that all clinical trial data should eventually
be put into the public domain for
unconditional, universal access,
but we see the current initiative as
an important, swiftly implemented, and successful first step. The
number of data requests submitted in the first 12 months after
the system was launched (58 requests) is a testament to the eagerness of the medical community to
reap the benefits of data sharing.
Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.
From Rutgers Biomedical and Health Sciences, Newark, NJ (B.L.S.); Hasselt Univer-
sity, Hasselt, and the International Drug
Development Institute, Louvain-la-Neuve
— both in Belgium (M.B.); the United Kingdom Clinical Research Collaboration Board,
London (J.H.); and the Center of Genomics
and Policy, McGill University, Montreal
(B.M.K.).
This article was published on October 15,
2014, at NEJM.org.
1. Ebrahim S, Sohani ZN, Montoya L, et al.
Reanalyses of randomized clinical trial data.
JAMA 2014;312:1024-32.
2. Nisen P, Rockhold F. Access to patientlevel data from GlaxoSmithKline clinical trials. N Engl J Med 2013;369:475-8.
3. Christakis DA, Zimmerman FJ. Rethinking reanalysis. JAMA 2013;310:2499-500.
4. Krumholz HM, Ross JS, Gross CP, et al. A
historic moment for open science: the Yale
University Open Data Access project and
Medtronic. Ann Intern Med 2013;158:910-1.
DOI: 10.1056/NEJMp1411794
Copyright © 2014 Massachusetts Medical Society.
Ebola Virus Disease in West Africa — Clinical Manifestations
and Management
Daniel S. Chertow, M.D., M.P.H., Christian Kleine, M.D., Jeffrey K. Edwards, M.D., M.P.H., Roberto Scaini, M.D.,
Ruggero Giuliani, M.D., and Armand Sprecher, M.D., M.P.H.
I
n resource-limited areas, isolation of the sick from the
population at large has been the
cornerstone of control of Ebola
virus disease (EVD) since the virus was discovered in 1976.1 Although this strategy by itself may
be effective in controlling small
outbreaks in remote settings, it
has offered little hope to infected
people and their families in the
absence of medical care. In the
current West African outbreak,
infection control and clinical management efforts are necessarily
being implemented on a larger
scale than in any previous outbreak, and it is therefore appropriate to reassess traditional ­efforts
at disease management. Having
cared for more than 700 pa­tients
with EVD between August 23 and
October 4, 2014, in the largest
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Ebola treatment unit in Monrovia,
Liberia (see diagrams), we believe
that our cumulative clinical observations support a rational approach to EVD management in
resource-limited settings.
Early symptoms of EVD include high fever (temperature of
up to 40°C), malaise, fatigue, and
body aches (see table).2,3 The fever
persists, and by day 3 to 5 of illness, gastrointestinal symptoms
typically begin, with epigastric
pain, nausea, vomiting, and diarrhea. Patients routinely presented
to our facility after 2 or 3 days of
severe vomiting or diarrhea, during which they posed a substantial risk to their communities and
had a high probability of testing
positive for Ebola virus in blood by
polymerase chain reaction (PCR).
Although some patients tested
positive on PCR within 24 hours
after symptom onset, we found
that a negative test result could
not be relied on to rule out disease until 72 hours after symptoms began. Of the patients who
tested positive for Ebola, none
that we were aware of had contracted disease from an infected
contact during the early febrile
phase of illness. No ancillary testing was available in our facility.
We observed that recurrent
episodes of emesis resulted in an
inability to tolerate oral intake.
Large volumes of watery diarrhea
estimated at 5 or more liters per
day (a manifestation not unlike
that of cholera) presented suddenly, persisted for up to 7 days
or (rarely) longer, and gradually
tapered off. Associated signs and
symptoms included asthenia,
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PE R S PE C T IV E
Ebola Virus Disease in West Africa
A
Triage
Discharge
Discharge
Confirmed cases
Discharge
Laundry, showers,
Pharmacy and latrines
Water tank
B
Incinerator
Stores
Visitors’ area
Office
Lowrisk
zone
Showers
and latrines
Meeting
tent
Entrance
for staff
Ward
Staff exit from
high-risk zone
Ward
Changing
area
Triage tent
Entrance
for patients
Morgue
Treatment
wards
Staff entrance
to high-risk zone
High-risk zone
(suspected cases)
High-risk zone
(confirmed cases)
Shower
Exit for cured patients
Natasha Lewer and Lou Lewer.
Diagrams of ELWA 3 Ebola Management Center, Monrovia, Liberia.
Panel A shows the high-risk zone, and Panel B shows the complete center. Adapted
from Médecins sans Frontières.
headache, conjunctival injection,
chest pain, abdominal pain, arthralgias, myalgias, and hiccups.
Respiratory symptoms, such as
cough, were rare. Commonly observed neurologic symptoms included delirium, both hypoactive
and hyperactive, manifested by
confusion, slowed cognition, or
agitation, and less frequently,
seizures. In the absence of adequate fluid and electrolyte replacement, severe lethargy and
prostration developed.
In approximately 60% of the
patients we cared for, the development of shock was manifested by diminished level of consciousness or coma, rapid thready
pulses, oliguria or anuria, and
tachypnea. The distal extremities
were cold despite high ambient
temperature, and peripheral vasoconstriction was apparent. In
aggregate, these clinical findings
suggested metabolic acidosis due
to severe hypovolemic shock. Evidence of hyperdynamic or dis-
n engl j med 371;22
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tributive shock was infrequently
observed and if present was a
late finding. Clinically significant hemorrhage from the upper
or lower gastrointestinal tract or
both occurred in less than 5% of
patients before death. Sudden
death occurred in a small fraction of patients who were in the
recovery phase of their illness,
possibly as the result of fatal arrhythmias. Most deaths occurred
between days 7 and 12 of illness.
Symptoms began to improve
in approximately 40% of patients
around day 10 of illness. We observed the development of oral
ulcers and thrush around this
time, associated with throat pain
and dysphagia. Nearly all patients who survived to day 13 ultimately lived. Our discharge criteria included 3 days without
gastrointestinal symptoms and a
negative PCR test for Ebola virus
in blood. We noted that some patients with initial evidence of
clinical improvement developed
neck rigidity and diminished levels of consciousness. These symptoms were associated with a slight
increase in late mortality. The
role of central nervous system involvement by EVD, secondary infection, or aseptic processes could
not be assessed.
Particularly vulnerable patient
populations included children
less than 5 years of age, the elderly, and pregnant women. Of
the four women who presented
with late second- or third-trimester pregnancies, three died shortly
after miscarrying, and none successfully carried a fetus to term.
Four Liberian staff members became infected with Ebola virus,
and three of them died. According to individual investigations,
these infections were not attributable to any known breaches in
november 27, 2014
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PERS PE C T IV E
Ebola Virus Disease in West Africa
Clinical Features of Ebola Virus Disease.
Phase of Illness
Time since
Symptom Onset
Clinical Features
Early febrile
0–3 days
Fever, malaise, fatigue, body aches
Gastrointestinal
3–10 days
Primary: epigastric pain, nausea, vomiting, diarrhea
Associated: persistent fever, asthenia, headache, conjunctival injection, chest pain,
­abdominal pain, arthralgias, myalgias, hiccups, delirium
Shock or recovery
7–12 days
Shock: diminished consciousness or coma, rapid thready pulse, oliguria, anuria, tachypnea
Recovery: resolution of gastrointestinal symptoms, increased oral intake, increased energy
Late complications
≥10 days
Gastrointestinal hemorrhage, secondary infections, meningoencephalitis, persistent
neurocognitive abnormalities*
*Secondary infections are presumptive diagnoses based on clinical features of distributive shock, oral or esophageal candidiasis,
and oral ulcers; meningoencephalitis is a presumptive diagnosis based on clinical features of unconsciousness and stiff neck.
infection-control procedures in
the Ebola treatment unit; instead
they are thought to be possibly
related to transmission in the
community where the outbreak
was active.
Health care workers in West
Africa remain overwhelmed and
challenged by the scarcity of resources that would be available
in developed countries for improving the care of patients with EVD.4
When patients arrived at our facility, they were moderately to
severely ill, and each physician
was responsible for the care of
30 to 50 patients. Direct patient
contact in the Ebola treatment
center was typically limited to intervals of 45 to 60 minutes two
to three times a day, owing to
substantial heat exposure and
fluid losses that providers experienced while wearing full personal protective equipment (PPE).
Under these conditions, physicians
had 1 to 2 minutes per patient to
evaluate needs and establish a
care plan.
Rapid clinical assessment required triage of patients into one
of three categories: those who
were clinically hypovolemic, not
in shock, and able to provide
self-care; those who were hypo-
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volemic, not in shock, but unable
to provide self-care; and those in
shock with evidence of organ
failure whose outcome would not
be altered by any available medical intervention. The majority of
patients we cared for were in the
first category. We believe that
this group had the highest likelihood of having a response to our
limited available interventions.
We observed that patients who
were hypovolemic, not in shock,
and able to care for themselves
had potential for recovery with
oral antiemetics, antidiarrheal
therapy, and adequate rehydration with oral electrolyte solutions. Given the massive fluid
losses observed with EVD, oral
antiemetics and antidiarrheal
therapy appear to be important
early interventions that may limit
life-threatening dehydration and
shock. In our experience, these
regimens were successful at
controlling symptoms, facilitated
oral intake, reduced gastrointestinal fluid losses, and helped to
reduce environmental contamination by body fluids. Health care
workers with limited time in PPE
were then able to direct their efforts toward encouraging and facilitating oral intake.
It was our impression that the
cohort of patients who were hypovolemic and not in shock but unable to provide self-care would
benefit the most from short-term
intravenous fluid therapy and electrolyte replacement. Establishing intravenous access, delivering
an adequate volume of fluid, and
ensuring safe management of
needles and devices required intensive individual-level patient care.
Routine use of intravenous fluid
therapy in our facility was prohibited by massive caseloads, limited
number of health care workers,
and limited time in PPE.
The central purpose of Ebola
treatment units has historically
been to isolate infected persons
early in the course of disease —
often soon after fever onset — in
order to break the chain of disease transmission in the community. However, all efforts must be
made to optimize the level of medical care provided within these
facilities. Resistance by infected
people to voluntary admission will
persist unless the treatment facilities are seen as a place to go
for treatment and recovery and not
as a place to die isolated from
loved ones and the community.
Our observations support aggres-
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PE R S PE C T IV E
Ebola Virus Disease in West Africa
sive use of antiemetics, antidiarrheal medications, and rehydration solution to reduce massive
gastrointestinal losses and the
consequences of hypovolemic
shock. Selective use of intravenous fluid therapy in the population that is most likely to benefit
is a rational approach under the
current circumstances. When possible, broader use of intravenous
fluid therapy and electrolyte replacement, guided by point-
of-service laboratory testing, is
likely to significantly improve
outcomes.
Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.
From the Liberia Mission, Médecins sans
Frontières, Brussels (D.S.C., C.K., J.K.E.,
R.S., R.G., A.S.); the Critical Care Medicine
Department, Clinical Center, National Institutes of Health, Bethesda, MD (D.S.C.); and
the Department of Infectious Diseases and
Tropical Medicine, J.W. Goethe-University
Hospital, Frankfurt, Germany (C.K.).
This article was published on November 5,
2014, at NEJM.org.
1. Feldmann H, Geisbert TW. Ebola haemorrhagic fever. Lancet 2011;377:849-62.
2. Tattevin P, Durante-Mangoni E, Massaquoi M. Does this patient have Ebola virus
disease? Intensive Care Med 2014;40:1738-41.
3. Kortepeter MG, Bausch DG, Bray M. Basic clinical and laboratory features of filoviral
hemorrhagic fever. J Infect Dis 2011;204:
Suppl 3:S810-S816.
4. Fauci AS. Ebola — underscoring the
global disparities in health care resources.
N Engl J Med 2014;371:1084-6.
DOI: 10.1056/NEJMp1413084
Copyright © 2014 Massachusetts Medical Society.
Illness Not as Metaphor
Perri Klass, M.D.
I
was precepting in the continuity clinic, when an intern came
to get me. She had already presented the 5-year-old child with
fever and sore throat and indicated that she wanted to do a rapid
strep, and I’d taken a look at the
child, who had obligingly opened
her mouth for me, and agreed
that she looked reasonably comfortable, well-hydrated, no respiratory distress, and her tonsils
were enlarged and erythematous.
Yup, I’d said, do the rapid strep
and then we’ll talk. And I’d returned to the precepting area.
Now the intern was embarrassed and apologetic. “I can’t
get it,” she said. “The child won’t
let me get the rapid strep. She
won’t say ‘Ah.’ I’m really sorry,
but now I’ve got her all upset.
What should I do?”
I was supportive and reassuring. It could happen to anyone, I
said, knowing that she was thinking I was just being supportive
and reassuring, that it couldn’t
really happen to someone competent. Let me come help you, I said.
And then I came up against
the demon child from hell. Let me
rephrase that: the child, who was
already feeling sick, was now emotionally distressed and unwilling
to cooperate with the insertion of
a cotton swab into the back of her
oropharynx. She signified this unwillingness by keeping her teeth
absolutely clenched, against all
the best efforts of her mother,
the intern, and me. And she was
successful. In the process of being successful, she made more
noise than you’d think a child
could make with her mouth closed
and generated a good deal of tears,
saliva, and snot. We started out
with the child sitting on her mother’s lap, enclosed in her mother’s
arms, and progressed to a completely losing proposition in which
she was lying on the exam table
with the intern basically lying
across her and holding her down
while her mother, who was now
also weeping, tried to hold her
head steady, and I pinched her
nostrils, smiled idiotically, and
said things like, “What a good
girl, just open a little bit, now,
we’re almost done!”
Well, we were never almost
done in the sense of getting the
rapid strep. Ultimately, I realized it
was up to me, the senior clinician,
to surrender, and so we did. I won’t
tell you what we ended up doing
clinically or how I rationalized it to
the intern — I’m sure you can
write those scenarios for yourself.
What I want to know is: Does
this story ring any literary bell?
Does it maybe remind you of the
classic 1938 short story by William
Carlos Williams, “The Use of
Force,” an often-anthologized,
often-assigned tale of a doctor
who makes a house call to see a
sick little girl? “She did not move
and seemed, inwardly, quiet; an
unusually attractive little thing,
and as strong as a heifer in appearance. But her face was flushed,
she was breathing rapidly, and I
realized that she had a high fever.”
The doctor-narrator decides he
needs to look at her throat: “As it
happens we had been having a
number of cases of diphtheria in
the school to which this child
went during that month and we
were all, quite apparently, think-
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2057